Welcome to the Podiatry Blog of Dr Richard Blake of San Francisco. I hope that the information here will help you in some way. Please feel free to leave a comment on the blog, or email me questions at drblakeshealingsole@gmail.com. If the blog helps you, consider a $5 donation to keep the blog growing. $25 has been donated in March 2018. Thank you. Dr Rich Blake

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Thursday, September 8, 2016

Sesamoid Healing Story

Hi Rich

I thought it may be motivating for your readers to have a positive story (hopefully continuing) as to healing the described sesamoid fracture.

After our last e-mail exchange in March I extremely strictly followed all advice you give on healing sesamoid fractures (taping, orthotic, dancers pad, contrast baths and exogen bone stim daily, stretching, PT, shoe with stiff sole, Vit D and Calc. intake, strictly no running and no barefoot, and being careful with any activity that could put too much pressure on the sesamoid, sometimes Super Elevation). I spent and am still spending almost one hour per day with these treatments on the fractured sesamoid (I learned to do something in parallel...).

It was a very bumpy road since March and every other week I was near to calling my doc to get an appintment for surgery as I had setbacks and flareups (increased swelling, redness, pain, etc.) with the very slowly, gradually increased activity. However, every other day there was a tiny bit of healing which kept me going on and of course also the advice on your blog. Learning about good and bad pain and accepting some pain (in particular for people like me with no pain tolerance) is essential. I would say I did not achieve pain level of 0 (=no feeling of the injury at all) during day (rather a 1-2) but I was and I am pain free at night and when I get up.

Now its 6 months after I broke it the third time and I have the first days where I am pain free throughout the day also with quite a bit of normal activity. Walks of up to 3 hours are possible without significantly increased symptoms (it still hurts a bit but as you say this reminds the contrast bathing and bone stim), and the PT is putting me on the treadmill. Due to the long relieving posture (walking on the outside of the foot) my foot and leg need to be brought back in shape (as it became slightly turned out of position) which probably will take a couple of more weeks.

I had another MRI done last week and there is still some inflammation visible according to the doc but no edema anymore and he believes that the two pieces have partially grown together but that there is some "filling up" with scar tissue. I still believe that he is wrong and the bipartite sesamoids are just very close to each other. So I continue conservative treatment and further increasing activity.

Maybe interesting for your readers: I did not use an Aircast or removable boot (due to my work) but a shoe with stiff sole (made by my orthopedic) as I was convinced after three times of re-breaking the bone that I do not need the boot as a reminder of the injury. I also dropped the icing as I had the impression there are nerves that did not like that and I was in more pain after the icing. I always taped the dancers pad (made myself out of foam rubber) to my foot as I wanted to avoid at all cost to step on the sesamoid and this also helped me at home to be safe on the hard floor of the bathroom etc.

The issue I see with the usual doctors that they do not know enough about these injuries. The mistreatments I received: carbon sole to insert into the shoe with thin foam sole for protection (after a couple of weeks the foam sole was worn out and I walked with the broken sesamoid directly on the carbon sole and ultimately rebroke it). Nobody knows about the dancers pad (which is in my view the most important element). They think healing takes the same amount of time as other bones in the foot and activity can be started too soon. As long as you are walking they do not really want to further investigate unless one insists.

Still there are a few questions to you:

Do you believe that also with sesamoid fractures after they have completely healed and double healed (and I am aware that this will take a couple more months) that they are harder to break than before, meaning that if I avoid the activity that caused the fracture, the protection of the bone can be reduced?

Dr Blake's comment: Yes, and no. All injuries to an area imply some form of weakness. Some times the weakness shows up in the form of ligament instability, some times with muscular weakness, sometimes (with sesamoids) due to the position against the ground and the driving force to push off. I know you have a high arch that makes the sesamoid more susceptible. You may also have a plantar flexed first metatarsal. These two combine to put pressure on the sesamoid. You are doing the right things, perfect in fact. As you go forward, you do not need to live in sesamoid fear, but you do need to be careful. I want 2 years of good activity out of you, with some sesamoid protection, before you ask that question again.

Are stress fractures less likely (I have a very high arch) after complete healing (and all inflammation has disappeared)?

Dr Blake's comment: Really back to the last question and why it happened in the first place. If it makes sense that you can avoid the original injury, and I know you know what puts too much pressure on the sesamoids, then you are probably okay. Stress fractures occur with too much pressure, and I know you can avoid this. Send me some photos on the bottom of your foot.

As I have bipartite sesamoid I am conscious about the potential ligaments between the two pieces and that they are at risk to be injured again with higher activity. Any idea in this regard as to protection?

Dr Blake's comment: Dancer's padding to off weight, orthotic devices to off weight, shoe gear that is stable and not too hard or soft in the sesamoid area, activities that do not place too much sesamoid pressure for the next two years while the bone gets stronger and stronger. I hope this makes sense. Rich

I will add something to the proposed donation as it was clearly your blog that helped me out of this really really bad (and sometimes almost depressing) injury and to get a normal life back. Dr Blake's comment: You are so kind.

8 comments:

Hi thank you for sharing! I've been dealing with a sesamoid fracture since June. I've seen 2 different doctors so far who have both seemed to know very little about this injury. I've learned so much from this blog. Can you share what stiff soled shoes you purchased? I need something for driving. I'm doing everything else that you are doing and hoping mine will heal also:

I also take it you continued to weight bear as normal? I use my scooter 90% of the time only weight bear when I absolutely have to. I can't seem to get the pain and swelling down enough to walk much more then that.

Hi Dr Blake, I'm Felicia from Singapore, and I wanted to email you but I couldn't find your email address.. I really hope you please read this and respond, even a quick short one, it will be so appreciated.

I'm in a state of anxiety and distress. In early June, my left foot swelled (the whole foot) and thinking it was just a sprain, I rested and checked with general practitioners, who sent me away with painkillers. The swelling went away within days and it wasn't really all that painful except for the nagging feeling that there was something wrong. (I think it was caused not from a particular incident but over time walking too much with heavy bags and increasing general fitness activity)

I had been taking pictures of both my feet for comparison and noticed that there is less fat on the pad of my left sesamoid and after trying to be more conservative about sports and doing sesamoid cut outs about 2 months later, I finally got my sports medicine specialist visit after countless of clueless GPs, who took an xray and showed me a clean lateral tibial sesamoid fracture. I was floored, because there was practically no pain and he said the fracture looked fresh. So I was put in a boot, and feeling really upset about things. At home, he told me I could wear some comfy slippers. I had read your blog and picked one with an arch support and stiff sole and was mainly concerned at the lack of inflammation and wondered if it would heal.

Pt 2:By this time in the boot I had stayed off mostly most exercises and only had to stand in trains, which started to hurt my right foot during the journey). Due to the boot height difference, I played around with shoe soles, and mistakenly stuffed up to 5 soles into my right running shoe to try to avoid hip pain from uneven leg length, but this eventually started hurting my right foot in various places, including the sesamoid. It was a very recent decision to have a cut out for my right sesamoid before the pain escalated into something, I thought.

2 weeks into the boot, I had tried doing some light weight bearing exercises and one of them being stationary boxing, with my left foot supported with a cushion and the right being on the floor with maybe a yoga mat folded, being careful to not pound my feet. I was happy to get a good workout, but shortly after my right foot started swelling in the sesamoid area. Alarmed, I rested it and believed it was sesamoiditis and really upset I blew my right foot too.. I let it rest for the night and went right away to a polyclinic for an xray...

The doctor didn't seem to know much about this condition and asked if my earlier xray showed a definite fracture, and I said yes. He told me it could be too early to see the fracture but I got it anyway. The results were that there is no visible sign of fracture, told me to wait and see, and if swelling persists, to get a repeat xray, and while I was relieved, I still felt it wasn't right.

The swelling in my right foot persisted, despite icing, or elevating. The whole ball of the foot is swollen and only the ball of the foot. When I touch it, the tibial sesamoid feels the most 'full' and slightly tender and the area closer to the second sesamoid is less full. The ball of the foot feels full My toe feels stiff and I can still scrunch my right toe with some effort. There is no pain (because I haven't tried to do anything with it. My left is already in a boot, and I borrowed a crutch for my foot to try to reduce weight bearing..I've never gotten a bone stim (never heard about it in Sg and doubt it's covered by insurance anyway).

Pt 3:Currently, I suspect it may be another fracture but I'm waiting to see if I can get a repeat xray. In your opinion, when would be a good time to get one? I'm worried it'll be too early, or if it's a stress fracture, it can't be spotted on xrays.. I'm seeing my physio therapist in another 10 days but specialist only at the end of the 8 weeks, which is 6 weeks more.. I'm going by company insurance which requires referral letters for specialist visits, so I'm not sure if I should wait another 5+ weeks to see the same specialist for both feet (and what should I do in the meantime? Immobilize both feet with double boot? <-- need referral from specialist *slaps forehead*) Get another xray before I see my physio therapist and hope he can help me, or try to get another referral to another podiatrist or specialist, one for each foot?

I'm so wrecked with worry and regret, and I am surprised I managed to bum both feet with reduced activity (I have high arch) and this frightens me. I have found alternate means to work which reduced my walking times to about 10 mins a time to and fro, with 1 crutch, I changed my exercises to all floor exercises that doesn't require putting foot to ground. I tried elevating, icing a few times, getting more calcium with pills and Vit D and eating less inflammatory food. I've been resting, and worried and depressed. I do not want to think that my right foot is fractured too, but I can't think of any sesamoiditis that has persistent swelling that won't go away. The lack of sharp pain in both feet (one with a confirmed fracture and one I'm not sure about) is making me doubt my own sense of pain sensation in my feet. I normally am really scared of pain, so I don't trust myself to even attempt weight bearing more than necessary. I've removed most of the soles in the right shoe and carefully cut out sesamoid cutouts so that it elevates that swollen area the best I know how. Some days I try to tape it, but it seems to irritate both feet. If I put my right foot on the ground, I can feel the tenderness (without placing weight) on the tibial sesamoid and some fluid that persists. Been monitoring for

I want to avoid surgery but I also want a faster recovery. Do you have any idea what might be going on, if non fractured inflammed sesamoids can persist swelling (does this mean my foot is not getting enough blood supply, getting too much, something is dying??) How long should I wait before getting a repeat xray, and if I should consider just getting 2 specialists one for each foot? I have a desk job, but I'm taking too many sick days for my feet and at this point I'm just scared I injured the right one worse than the left.

Also.. how do you advice patients on coping with stress and worry during the recovery? I fear my mental aspect is deteriorating..

Hi Sadie, as to the stiff sole my orthopedic basically cut open a regular shoe and directly built it in incl. a rocker bottom. During the last 6 months I walked (after six weeks NWB on crutches) but always with almost none weight on the injured area.

Thanks so much for your blog-- it's full of great information. Like Felicia, I wanted to email you but was unable to find your address. I'd really appreciate some advice on an appropriate course of treatment for my situation. A little background: I'm a runner, but have been mostly sidelined for a couple of years due to a hamstring injury. My other primary physical activity is rock climbing, which I've been doing for 8-9 years.

Back in April, I suddenly developed pain in the ball of my right foot, unrelated to any injury or activity as far as I could tell. There was noticeable swelling, mostly evident on top of the foot. I limped along for a while, but after the first few days, the pain was never enough to make me seek medical attention. About a month later, I developed intense pain more toward my 2nd and 3rd toes, which left me unable to bear weight at all for a couple of days. That pain settled down, but it caused me to consult a podiatrist. He took x-rays, but didn't see anything. He recommended OTC insoles and no longer going barefoot.

I stopped climbing for a while, then restarted using only the outer edge of the foot. I was also running about once a week, no more than 5K. I continued to have pain when walking, some good days and some bad days. Interestingly, I often had less discomfort when running than when walking. I stopped climbing again in early November, because I was uneasy about the ongoing pain.

In December, I went to see an orthopedic specialist, because the pain had been going on so long. He took new x-rays, and they clearly show that one of my sesamoids is fractured-- a small chunk has broken off of it. On his advice, I got a Morton's extension. I'm also changing up my footwear-- have just purchased some stability shoes from Hoka One One, with a rocker style sole.

In your opinion, given how long the fracture went undiagnosed, what measures should I be taking? Is what I'm doing sufficient, or should I be getting custom orthotics, or should I be asking for full immobilization even at this late date?

Thank you very much for leaving a comment. Due to my time restraints, some comments may not be answered.I will answer questions that I feel will help the community as a whole.. I can only answer medical questions in a general form. No specific answers can be given. Please consult a podiatrist, therapist, orthopedist, or sports medicine physician in your area for specific questions.

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About Me

I have been a podiatrist for 34 years now and I am excited about sharing what I have learned on this blog. I love to exercise, especially basketball and hiking. I love to travel. I am very happily married to Patty, and have 2 wonderful sons Steve and Chris, a great daughter in law Clare, my new grandson Henry, and a grand dog Felix.